Haven of Tucson

Inspectors wroteBased on facility observations, staff interviews, record review, and review of facility policies, the facility failed to ensure that one shower room was maintained in a clean and safe condition in accordance with professional standards of practice. This deficient practice had the potential to affect residents by failing to provide a clean, safe, and homelike environment. The sample was 1 of 1 and the census was 121. Findings Include:Resident #15 was admitted to the facility on [DATE], with diagnoses including heart failure, hypertension, Type II Diabetes Mellitus, respiratory failure, and other comorbid conditions. Resident #15 was one of the residents on the Heritage 200 hallway who had recently received a tracheostomy due to respiratory failure. [...]

Inspectors wroteBased on clinical record review, interviews, and review of facility policy and procedure, the facility failed to ensure one resident was referred for a level II Pre-admission Screening and Record Review (PASRR). The universe was 21. The deficient practice could result in residents not receiving the appropriate level of care needed to achieve their highest and practicable wellbeing.

Inspectors wroteBased on clinical record review, observations, interviews, and review of the facility's policies and procedures, the facility failed to ensure one resident, #4, was monitored and assessed for changes in her condition. The universe was 21. The deficient practice could lead to residents having an adverse health event as a result of not being monitored adequately.

Inspectors wroteBased on personnel file review, staff interview, and facility policy review, the facility failed to ensure one of two sampled Certified Nursing Assistants (CNA/Staff#98) maintained current Cardiopulmonary Resuscitation (CPR) and First Aid certification. The facility also failed to follow its policy requiring one Registered Nurse (RN/Staff#90) to remain in non-probationary status. The deficient practice could place residents at risk for delayed or ineffective emergency response and for receiving care that does not meet accepted standards of care.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to implement its policy to ensure that an allegation of neglect for 1 (Resident #1) out of 5 residents was reported to all applicable state agencies. The deficient practice could result in further allegations of neglect not being reported.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure an allegation of neglect for 1 (Resident #1) out of 5 residents was investigated. The deficient practice could result in further neglect of residents and appropriate corrective actions not being taken.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure physician-ordered laboratory and intravenous treatment was administered as ordered; and failed to ensure the physician was notified of a critical laboratory result for 1 of 3 sampled residents (#22). This deficient practice resulted in the resident not receiving the prescribed and appropriate treatment needed, resulting in further decline.

Inspectors wroteBased on observation, record review, interviews, and facility policy, the facility failed to ensure that monitoring and evaluation of physical restraints are completed for the continued use of physical restraints for one resident (Resident #62). The deficient practice could lead to increased isolation and/or other psychosocial harm.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to ensure professional standards were met during medication administration. The deficient practice could result in the spread of infection and undesirable medication- induced harm. The facility census was 106, and there were 22 sampled residents.

Inspectors wroteBased on observations, interviews, review of clinical records, and review of facility policy, the facility failed to ensure one resident (#46) received assistance to maintain hearing ability. This deficient practice can result in in-effective communication. Findings Include, Resident # 46 was admitted to the facility on [DATE], with diagnoses of a right pelvic fracture, atrial fibrillation, anticoagulant therapy, anxiety, depression, and lack of coordination. The resident's inventory dated November 27, 2024 failed to list hearing aids under the resident's personal property. The resident's order dated November 27, 2024 revealed the resident could be seen by an audiologist. The care plan dated November 27, 2024 with the download date of December 16, 2024, revealed no focus, goals, or interventions for resident's hearing. [...]

Inspectors wroteBased on staff interviews, clinical record review, and facility policy, the facility failed to ensure that one resident (#149) was not discharged with an unnecessary device. this deficient practice could result in infection and increased risks of death. Resident #149 was admitted on [DATE] with diagnoses of urinary tract infection, Klebsiella pneumoniae and type 2 diabetes. This resident was discharged to an assisted living facility on February 6, 2024. A care plan initiated on January 16, 2024 included that the resident was on Antibiotic Therapy including Meropenem for a urinary tract infection. Interventions included to observe for possible infection every shift. [...]

Inspectors wroteBased on clinical record review, interviews, facility documentation and policy, the facility failed to ensure that one resident (#74) was weighed on admission. This deficient practice can impact the nutritional and hydration needs of the residents.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure medications were disposed of according to accepted professional standards. The deficient practice of erroneous medication disposal may result in undesirable medication- induced harm. The facility census was 106, and there were 22 sampled residents.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to ensure appropriate infection control practices were followed during medication administration. The deficient practice could result in spread of infection. The facility census was 106, and there were 22 sampled residents.

Inspectors wroteBased on staff interviews, review of records and facility policies and procedures, the facility failed to ensure that medical records were documented accurately and in accordance with accepted professional standards and practices for one resident (#1) regarding fall risk assessments. The deficient practice could result in inaccurate documentation of the residents medical history and needs.

Inspectors wroteBased on staff interviews, review of records and review of policies and procedures, the facility failed to ensure that physician orders were in place for fall preventative measures, regarding fall mats for one resident (#1). The deficient practice could result in non-ordered services being provided for residents.

Inspectors wroteBased on resident and staff interviews, clinical record review, and review of policy, the facility failed to ensure one resident (#127) received care and services to restore and/or maintain continence. The sample size was 18. The deficient practice could adversely impact the resident's dignity and result in bowel and bladder continence not being maintained.

Inspectors wroteBased on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to conduct an ongoing review for antibiotic stewardship as required by Center for Medicare and Medicaid Services (CMS) guidelines, and failed to review clinical signs and symptoms and laboratory reports to determine if antibiotics are indicated. The deficient practice could have the potential for residents to have adverse effects due to the lack of protocols and monitoring.

Inspectors wroteBased on clinical record review, interviews, and review of facility policies, the facility failed to ensure that medications were available as ordered for one resident (#2). The deficient practice could result in not receiving medications that are physician ordered and necessary.

Inspectors wroteBased on clinical record review, staff interviews, observation, facility documentation and policies and procedures, the facility failed to provide food that accommodates resident allergies, intolerances, and preferences for two residents (#125, #126).